Tackling drug-abuse is a national priority, er, depending on where you live

There is a strong commitment within government to drug policy and particularly drug and alcohol treatment. This is evidenced by the cross-departmental representation on the Inter-Ministerial Group on Drugs and, despite exceptional pressures on public spending, the decision to allocate £570m to the ring-fenced ‘pooled treatment budget’ for England for 2011-12 (a relatively small reduction in cash terms of under two per cent).

The government’s drug strategy, published in December 2010, sets out a new ambition for improving drug and alcohol treatment and supporting people in their recovery.  As a ‘high level’ document, the strategy is short on specific targets and measurements, but in setting out what needs to change and happen, it is bold and ambitious.

While it is clear that a ‘drug-free life’ is at the heart of the recovery ambition, the strategy avoids a simplistic and exclusive focus on ‘abstinence’, recognising that recovery ‘is an individual, person-centred journey…that will mean different things to different people’.

At first blush, the headlines from the drug strategy may not seem so different from the direction of travel latterly set out by the previous government with its greater focus on ‘reintegration’ for problem drug users.

It would be wrong to deny some continuity, but the new strategy is distinctive in articulating the essential building blocks for recovery and recognising the critical importance of ‘recovery capital’ — social, physical, human and cultural — requiring access to a range of services to address the needs of the whole person, such as education, training, employment, housing, family support and wider health services.

The messages on commitment and ambition (shared by the vast majority of the drug and alcohol sector) are clear — but what about delivery?

The reality is that the vision for recovery has to operate within a wider policy and political context —making delivery complex and challenging. The government’s wider policy reform agenda — in criminal justice, welfare reform, housing and health -— impacts directly.  The difficulties in delivering goals and outcomes in a national strategy are increasingly evident in an age of ‘localism’ — there has been a bonfire of national targets, performance measures and ring-fences.

Huge changes are underway which will effectively replace the structures and frameworks that drove the expansion of drug treatment over the last ten years.

The drug and alcohol treatment sector is not immune from public service reform. Payment-by-results is widely used in the NHS and increasingly in the welfare and criminal justice systems — its extension into drug treatment for people with often quite complex, differing and variable needs linked to their dependency is unprecedented.

Eight ‘drug recovery payment-by-results’ pilots will be in place from April 2012, but with the green-lighting of outcome-based commissioning for drug treatment, many local areas are introducing different forms of payment by results. Some issues are inherent: avoiding ‘gaming’ or perverse incentives such as cherry-picking clients, establishing what outcomes are to be paid for, and the timing of payments (for example, how much, if any, is paid ‘upfront’) and the impact on cash- flow.

Access to a range of services and support is vital for recovery. The ability to access and sustain suitable accommodation is, for example, one of eight ‘best practice outcomes’ specified in the drug strategy as being key to successfully delivering a recovery-oriented system.

Despite this very welcome emphasis, the Recovery Partnership (the Recovery Group UK, the Substance Misuse Skills Consortium and DrugScope) in a paper for the Inter-Ministerial Group highlighted concerns about access to housing, and particularly Supporting People funding, housing allocation policies and the potential impact of housing benefit and other social security reforms.

Employment is also identified as a key outcome for recovery and it is clear that the Secretary of State for Work and Pensions, Iain Duncan Smith, is passionate in his commitment to improving opportunities for people with drug and alcohol problems.

The combination of policy reform and localism is most dramatic with the introduction of the new public health service — from April 2013 it will present particular and significant challenges for drug and alcohol treatment services. Key functions of the National Treatment Agency (which oversees drug treatment spending and performance) will transfer to Public Health England, a new executive agency tasked with leading on public health.  

It is expected that up to half of local public health budgets — over £1bn a year — will represent current spending on drug and alcohol treatment services. At a time when local authorities are acquiring responsibility for drug and alcohol treatment they will be managing unprecedented cuts to their budgets of about a quarter over four years (or more, given the Chancellor’s announcement in the Autumn Statement that there will be two further years of spending reductions)

 

 

 

There is much in favour of local authorities having more control and ability to respond flexibly to local needs, to pool budgets without rigid ring-fencing harnessed to central targets and to integrate drug and alcohol services with other local strategies. But there are risks, particularly of cuts in drug and alcohol services or disinvestment. The warning signs are there.

Although there will be a nominal ring-fence around the total public health budget, there will no longer be a ring fence for drug treatment. Drug and alcohol misuse were barely referenced in the public health white paper Healthy Lives, Healthy People nor in the ‘update and way forward’ document published by the Department of Health last July.

A local authority chief executive, elected council member or director of public health would not have a clue that as much as half of public health service budgets represent drug and alcohol treatment. The update and way-forward document includes drug and alcohol misuse services as one of 17 potential responsibilities for Health and Wellbeing Boards, along with, for example, tobacco control; obesity; public mental health services; accident injury prevention; preventing cancer and other long-term conditions; sexual health and reducing winter deaths.

The Health Select Committee in its report on public health (November 2011) highlighted the risk of local authorities ‘gaming’ the system by redesignating services as ‘public health’ spending (for example, filling in potholes  reduces road accidents, which reduces hospital admissions and thereby improves ‘public health’).

Despite flagging this concern, it was worrying that the Committee had little to say about drug and alcohol treatment or the risk of disinvestment and its impact.

At the time of writing, the government is finalising a set of national outcomes for the public health service and officials and ministers with an interest in tackling drug and alcohol harms are acutely aware of the risks as well as the opportunities.

Ministers fought hard to maintain central government funding for the Supporting People programme, but with the ring- fence removed many local authorities have made deep cuts — despite evidence that the programme supports the most vulnerable, that demand may rise and that it provides excellent value for money. The value in cash terms of central government funding for young people’s drug and alcohol treatment has been maintained, but with budget pressures elsewhere local services are being cut.

Tension arises when local decisions compromise national strategies — whose mandate is then supreme? If government lacks the levers to deliver, what then is the purpose of a national strategy?

There is an aversion within government to producing guidance — but information, advice and quality standards from ‘the centre’ need not conflict with localism, particularly at a time of transition and uncertainty.

The establishment of the ‘Troubled Families Team’ headed by Louise Casey is an example of how government can motivate, incentivise and drive local policy and practice from the centre. Public Health England needs to be given the levers and a clear mandate, underlined by a clear message from government, on maintaining the investment in drug and alcohol treatment.

 

 

 

There are risks with localism, but there is also an opportunity to shift attitudes to people with drug and alcohol problems and those in treatment and recovery. In one survey, three-quarters of employers said they would not knowingly employ someone with a past history of problem drug-use even if they were otherwise suitable for the job, yet evidence also shows that people in recovery are committed and hard-working employees.

Despite the strong commitment within government to treatment and supporting recovery, this is a critical and uncertain time for the drug and alcohol sector. The sector knows that it needs to ‘up its game’ on changing culture, working practices and achieving better and sustained outcomes — but the environment is challenging.

The drug strategy sets out a compelling vision which can engage and motivate local communities, but localism in a period of austerity risks disinvestment for a stigmatised group. If we get this wrong the consequences will be far-reaching and devastating for people willing to make the commitment to turn their lives around and begin the recovery journey, as well as their families and communities.

If we get it right, there will be tangible benefits for all, including the taxpayer — reduced crime, troubled families, unemployment and so on. Achieving the ambition for recovery is a litmus test of the government’s commitment to the most vulnerable and to achieving social justice.

Noreen Oliver MBE is chief executive officer of BAC O’Connor Centres and Martin Barnes is chief executive of DrugScope.